THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, THE “PHARMACY OF THE FUTURE” WILL BE SHAPED BY DEMOGRAPHIC, ECONOMIC AND REGULATORY CHANGE; THE TRANSFORMATION OF PRIMARY HEALTHCARE; NEW DIGITAL INFORMATION TECHNOLOGIES AND THE RISE OF MULTICHANNEL RETAILING.

This is the first instalment in a series of healthcare insights that will be released at intervals by Alvarez & Marsal (A&M).

2 CONTENTS Introduction 4 The Six Key Factors That Will Shape “The Pharmacy Of The Future” 5 The Opportunity To Transform Primary Healthcare 10 How Ready Are You To Play? 11 How A&M Can Help 12 Key Contact 14

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 3 The pharmacy of tomorrow will be shaped by the convergence of the dramatic changes taking place in multi-channel retail and INTRODUCTION primary healthcare, catalysed and enabled by six key trends, namely: The digital revolution has spawned new business models that 1. Pharmacy industry consolidation and performance deliver better, cheaper, more relevant services to consumers. improvement, encouraged by reducing government subsidies As individuals, we are accustomed to interacting with retail and and the need to strengthen pharmacy economics other organisations in new ways. We shop online, bank online, organise our lives online and consume all manner of content 2. The adoption of true multi-channel retail practices and digital online. Our physical interactions with businesses and public consumer engagement by , including the provision sector organisations are increasingly part of a multi-channel of a wider range of health-related services in store and online experience with, for example, retailers now having to rethink what their stores are for, where they should be and what they put in 3. Expanding the role of the as a focal point in the them. The UK is in the vanguard of this retail transformation, as it local community for primary care, with access to medical is in other sectors that are being transformed such as insurance records and enhanced prescribing powers and government. 4. Progressive improvement in medical records management, We are about to see similar transformational change in including the adoption of GS1 data standards and permission- primary healthcare driven by pressure on government based access across the primary care (and wider) health budgets, demographic shifts (including ageing populations) system and increasingly health-conscious, digitally savvy and value- driven consumers. This has the potential to reduce pressure 5. New approaches to monitoring patient health and on hospital accident and emergency (A&E) departments and compliance that could enable further transfers of responsibility general practitioner (GP) practices, improve patient outcomes to local primary care and substantially reduce the overall cost of care. The community 6. New analytical techniques that transform the way pharmacies pharmacy will play a key role in this transformed primary will engage with their local communities and the way physical healthcare model but it will look somewhat different from the pharmacy footprints will be reshaped pharmacy we know today. This article describes the profound changes we see taking place in pharmacy retail. We anticipate equally profound changes across the wider healthcare system, including significant impacts on suppliers to the system such as manufacturers of medicines. These will be covered in subsequent instalments.

4 medicines are being reduced or limited to the cheapest generic version of a . In countries such as South Korea, economic THE SIX KEY evaluations have been introduced for the first time to prescription FACTORS THAT WILL reimbursement criteria. There is evidence of a trend towards liberalisation of pharmacy SHAPE “THE PHARMACY markets, moving towards a US style model that is without restrictions on ownership or corporate structures, establishment rules and limitations on sales of OTC medicines. For example, in OF THE FUTURE” Sweden, establishment rules were recently abolished, resulting in state-owned pharmacies no longer dominating the market. 1. PHARMACY INDUSTRY CONSOLIDATION AND PERFORMANCE IMPROVEMENT, ENCOURAGED In the US, this more liberal approach has led to pharmacies BY REDUCING SUBSIDIES AND THE NEED AND becoming increasingly consolidated, with several large mergers OPPORTUNITY TO STRENGTHEN PHARMACY and acquisitions in recent years. Provisions in the Affordable ECONOMICS Care Act and pressure on prescription margins have also prompted US pharmacies to diversify more into specialty The structure of the pharmacy sector differs by country, being and non-dispensing revenue streams, such as health significantly influenced national regulatory environments. Across clinics, opticians and dental care. We expect to see similar trends Europe, Asia and Africa, regulations restricting ownership and emerging in other countries. rules around establishing new pharmacies are common. In some countries, including France, Germany, Italy and Spain, chains of While some pharmacies do an excellent job of ranging and pharmacies are not permitted. This has resulted in a fragmented merchandising beyond the core business of dispensing and retail environment dominated by independently run pharmacies, selling OTC medicines, many others have significant opportunities though this does not prevent them from being members of more to improve their customer offer and business performance loosely associated buying groups. It is estimated that in Europe, through better ranging and presentation. In particular, many 80 percent of pharmacies are independent, with only 16 percent pharmacies have opportunities to be more proactive in managing belonging to wholly-owned chains. Of these, major chains with their non-prescribing space according to mainstream retail at least 50 branches account for 46 percent, and approximately performance metrics such as sales density and gross margin half of the wholly owned chains in Europe are found in the UK. In return on space. emerging markets, this fragmentation is additionally driven by the prevalence of traditional trade retail models. Reductions in government support will likely encourage these changes, while also resulting in the rationalisation of the number Most countries also regulate pricing and the availability of over the of pharmacies as some fail to rise to the challenge or lose out to counter (OTC) medicines, typically restricting sales to pharmacies nearby competitors that are more successful in becoming real or (as in Canada, UK, Singapore, South Africa and Australia) primary healthcare destinations. We see a particular opportunity allowing certain “general sale” OTC medicines to be available for many pharmacies to adopt more explicit patient pathway elsewhere. Pharmacies may also receive a portion of their income thinking whereby products that complement prescription in the form of fixed fees for dispensing (as is seen in countries medicines and treatments, such as those tackling unwanted side such as the UK, Belgium, Italy and the Netherlands). effects, are recommended at the time a prescription is dispensed. We also see this as an opportunity for the manufacturers of However, pressure on healthcare budgets has led to government complementary products, such as OTC medicines and nutritional reducing this support for pharmacies, creating an important supplements, to bring proactive patient pathway and “category shift in pharmacy economics. This shift has particularly targeted management” thinking to pharmacies. reimbursement models, where subsidies for prescription

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 5 2. THE ADOPTION OF TRUE MULTI-CHANNEL RETAIL customers, prompting replenishment purchases, making relevant PRACTICES AND DIGITAL CONSUMER ENGAGEMENT offers and inviting them to the store for check-ups and treatments. BY PHARMACIES, INCLUDING THE PROVISION OF A We believe customers and patients will generally welcome this WIDER RANGE OF HEALTH-RELATED SERVICES IN type of closer relationship with their neighbourhood pharmacy STORE AND ONLINE and that this will be an important foundation for the successful pharmacy of the future. Individuals can increasingly choose to consume healthcare services in different ways, with delivery models reflecting what Digital technologies are already beginning to revolutionise the is happening more broadly in retail, i.e. becoming truly multi- in-store pharmacy environment, including the ways in which channel. A number of countries now permit online purchases of prescriptions are fulfilled. OTC and prescription medicines, leading to existing pharmacies Electronic Prescriptions and Robotic Dispensing developing multi-channel offerings, as well as to the entry of “pure play” online pharmacies. In Europe, large online and mail Electronic prescriptions have already been introduced in the UK, order pharmacies have been established in the UK, Germany, helping to ensure timely and accurate prescription fulfilment. the Netherlands, Poland and Switzerland. Multi-channel models Warehouse automation already plays a clear role in efficient also open up opportunities for pharmacies to expand their share central fulfilment. Pharmacy robots could be the next step in of wallet in other product categories and offer a wider range of improving the speed, efficiency and accuracy of dispensing and health-related services. optimising the use of space in the pharmacy.

“Click & collect” is becoming commonplace in retail and has a The Growing Role of In-Store Customer Technology strong place in the future pharmacy model. Patients want to know More and more pharmacies are implementing in-store that the medicine (prescription or OTC) or medical device they touchscreens to allow customers to search for information about are looking for is in stock before making a trip to the pharmacy. the medicines they are being prescribed and to obtain other In areas where the patient has a choice of pharmacy, this could health advice. With the ever-growing adoption of intelligent mean the difference between the patient going to the smaller connected mobile devices, it is inevitable that market-leading local pharmacy over a larger supermarket-based pharmacy due pharmacies will choose to give access to this information via their to the certainty of availability. As a result of their location in the customers’ own devices. This could be further enabled through community, many pharmacies have the opportunity to play a role exploitation of technologies such as QR codes and beacons. as a click & collect location for a number of retailers, which some These technologies allow customers to be directed to specific chains have already started to take advantage of to drive footfall information on their own device. For example, a QR code on a into their stores. The counter in the pharmacy already provides poster about diabetes could direct a patient to information on the some of the infrastructure required to support click & collect and condition and related products in stock in the pharmacy. hence the cost need not be significant for each outlet as long as Digital screening technologies are also increasingly being used as volumes and types of merchandise are manageable. part of new patient health checks in the pharmacy and we expect At the heart of most effective multi-channel retail models lies a this to grow rapidly as the underlying technologies advance. single, integrated view of the customer reflected in a wide range Examples include screening for blood disorders, cardio-vascular of data about, for example, their socio-demographic profile, problems, early-stage diabetes, glaucoma, common skin cancers household details, transaction history, etc. Modern advanced and perhaps even the warning signs of mental deterioration. analytics can exploit this data to more effectively engage with

6 3. EXPANDING ROLE OF THE PHARMACIST AS A FOCAL 4. PROGRESSIVE IMPROVEMENT IN MEDICAL POINT IN THE LOCAL COMMUNITY FOR PRIMARY RECORDS MANAGEMENT, INCLUDING THE ADOPTION CARE, WITH ACCESS TO MEDICAL RECORDS AND OF GS1 DATA STANDARDS AND PERMISSION-BASED ENHANCED PRESCRIBING POWERS ACCESS ACROSS THE PRIMARY CARE (AND WIDER) HEALTH SYSTEM In many countries, represent a significant under- utilised resource in primary healthcare provision and we expect We are facing a revolution in healthcare provision, with the use policymakers to address the regulatory changes needed to of data being the catalyst and enabler of this transformation. expand their role in primary healthcare for communities. The sharing of information between healthcare professionals is largely driven by the ambition to provide the best and safest In the UK, for example, a pilot scheme is underway that involves healthcare possible. Improved data capture and analysis also has giving 100 pharmacies access to patients’ “summary care the potential to reduce the costs of care, which also motivates records” which contain information such as allergies and current healthcare governors, leaders and managers. medications. Creating and, more importantly, using data requires standards, The UK Royal Pharmaceutical Society estimates that treating rigour and ease of data capture at every point in patient pathways, common ailments such as coughs and colds in pharmacies could combined with the right tools to interpret and make it available for save the National Health Service (NHS) over £1 billion a year. use in planning and delivering patient care, post-event analytics and proactive risk management. With the proposed changes in regulation, UK patients with minor ailments could opt to visit a pharmacist instead of In the UK, as in a growing number of other countries, NHS their GP surgery. Pharmacists would be allowed to provide a policy is to adopt GS1 standards in areas such as patient broad range of services such as vaccinations, health checks, identification, treatment details, drug administration, equipment smoking cessation programmes, minor ailments management, use etc., which has the potential to provide a critical foundation medicines assessment and compliance support, care services, in the endeavour to improve and personalise care, strengthen substance / alcohol abuse services, sexual health screenings, regulatory compliance, capture learnings, avoid repeated mistakes weight management services, gluten-free food supply and and reduce waste. It is also clear that these new data disciplines supplementary / independent prescriptions. need to go beyond the NHS trusts to include other participants in the broader health ecosystem such as GP practices, This would also mean that UK visits to accident and emergency pharmacies, pharmaceuticals manufacturers, medical equipment departments could reduce by as many as 650,000 and GP manufacturers, distributors and the private healthcare sector. consultations by 18 million. Only one-third of UK pharmacies currently have minor ailment centres but we expect this to An increasing number of countries are allowing, or considering to change significantly over the next three to five years, consistent allow, pharmacies to access patient medical records. In France, with changing regulation and the expansion of the role of the for example, the "Dossier Pharmaceutique" allows pharmacists to pharmacy. We see a similar opportunities across the rest of view four months of a patient’s medication history and 21 years Europe, and more broadly across both developing and developed of vaccination history. Enabling the pharmacist in this way, in markets around the world. conjunction with enhanced prescribing powers, has the potential to reduce prescribing errors and improve patient outcomes, as well as to reduce costs since the cost per intervention by a pharmacist is estimated to be significantly lower than that of a GP or nurse.

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 7 5. NEW APPROACHES TO MONITORING PATIENT wearable technology to monitor patients’ health, assess health HEALTH AND MEDICATION COMPLIANCE THAT risks and aid medical research. The data the app collects can be MAKE IT POSSIBLE TO TRANSFER FURTHER monitored, with an alert raised to the pharmacist if there are any RESPONSIBILITY TO LOCAL PRIMARY CARE unexpected results in tracking someone’s condition.

The digital revolution is now starting to transform the way DIY Healthcare individuals are monitoring and managing their own health. Numerous new products are under development that will enable Smartphones are already allowing and encouraging individuals patients to monitor their vital signs and conduct simple tests (e.g. to monitor their exercise patterns and body responses. Other urine samples) themselves. These devices will also be able to wearable devices will take this further and many individuals will share information with healthcare professionals, for example using make this data available to healthcare professionals, thereby a patient’s smartphone. providing a much more complete understanding of their lifestyle and health than has ever been available before. Not only do these Adherence Monitoring technologies have the ability to provide much more complete and Monitoring of patients’ prescription compliance is a key area up-to-date diagnostic information, but they will also allow remote where digital technology can improve patient outcomes and monitoring of compliance with treatment regimes. They can also reduce waste. Products range from “smart packaging,” where provide an emergency warning system when things go wrong, blister packs containing microchips can monitor when a dose is bringing huge beneficial implications for care for the elderly and popped out, to “smart pills” that are ingested by the patient and for others at risk. transmit data on doses taken to a patch on the patient’s skin.

Beyond individual care, the analysis of this new data, using the Home Technology and Remote Monitoring latest generation of intelligent data analytics tools, will have a An increasing number of products, technologies and services crucial role to play in informing care strategies, improving patient are available to assist long-term healthcare and monitoring for outcomes and reducing all manner of causes of misdiagnosis, the elderly and other patients at risk while at home, including the misprescribing and waste. It will bring a better understanding of tracking of blood pressure, mobility, heart rate and many other key the lifestyle and other factors that influence patient outcomes, health indicators. Examples of recent innovations include floor drawing on structured data and many different sources of pads in elderly patients’ homes to monitor physical movement and unstructured data, both directly attached to the patient’s medical locations and report any divergence from expected daily patterns, records and beyond, such as those describing the environmental and plugs that detect whether a person has used their appliances factors influencing the individual. as per their normal routine, sending an alert to a relative or carer if their behaviour is unusual. Social Media and Apps Social media and app-based solutions will allow pharmacists Clearly, the data privacy and security requirements around these to share medication and health news with customers, including new approaches to monitoring and managing consumer health alerting them when prescriptions are ready or when regular blood are significant and some individuals will be reticent to share their tests or other check-ups are due. Many patients already use personal information or allow it to be accessed. The relevant social media to share health tips and advice with each other or regulatory regimes are in their infancy, with much work to be done as part of support groups. We expect leading pharmacists to take on exactly what information will be available to whom, such as the an increasingly active role in such groups to ensure the correct pharmacist, and in what circumstances. On balance though (and advice is given and to promote the pharmacy. Reviews could have pilot adoption of these concepts in locations such as Switzerland a place in helping customers choose between OTC medicines or and the UK would tend to support), we believe these new medical supplies. Apps are also being used in conjunction with approaches will be widely accepted as a key foundation for the provision of better, more affordable healthcare in the future.

8 6. NEW ANALYTICAL TECHNIQUES THAT TRANSFORM Broader Commercial Opportunities THE WAY PHARMACIES WILL ENGAGE WITH THEIR It is important to also address the broader commercial opportunities LOCAL COMMUNITIES AND THE WAY PHYSICAL that present themselves alongside the vital public service PHARMACY FOOTPRINTS WILL BE RESHAPED provided by pharmacies, as exploiting these opportunities will add considerably to the overall viability of pharmacies and greatly Profound changes in shopping behaviours are taking place improve investment returns. For example, it might make sense for driven by the widespread adoption of digital technologies and by health and pharmacy centres which focus on fitness services to demographic and lifestyle changes. These are already substantially establish activity related facilities such as secure cycle parking. For impacting demand patterns across the retail landscape. For others, the emphasis might be on well-being for the elderly with example, retail frontages are locating close to concentrations of mobility and other relevant products and services offered. employment and major tourist attractions, while transportation hubs are increasing their share of retail expenditure. As a The range of formats will be easily distinguished and their mix generalisation, the top retail destinations, which benefit from these in a given region will be better aligned with the overall demand multiple sources of demand, together with the locally convenient profile, with individual formats locally placed to reflect structural centres serving residential, employment and commuter-based peaks in particular needs and potential demand that can be met demand, will continue to flourish. However, the majority of middle- in commercially attractive ways. Health education should also be ranking retail venues, especially second-tier shopping malls, will tailored to local priorities and needs rather than being deployed continue to suffer declines in footfall and turnover universally in a “one size fits all” manner.

Pharmacy provision will need radical transformation to take The Importance of Effective Retail Execution account of these polarising trends if performance is to be The volatility of demand during the trading day and trading optimised. There is little evidence that the supply of store-based week will increasingly challenge pharmacy operators to develop pharmacy services has begun to address this challenge in a operational solutions to ensure that the highest standards of significant way. service and professionalism can be maintained at the points of greatest stress. Disciplined category selection and ranging will Store Location and Format Choice be required to maximise sales densities on expensive and limited Increasing availability of data will inform choices of pharmacy retail space and that the pharmacy is equipped to meet the needs locations in the future, as well as enable the products and of customer and patients when they visit the store. This will deliver services that they provide to be tailored to the catchment area healthy commercial and financial prospects for the pharmacy, in within which they operate. As already demonstrated in mainstream spite of the likely need in many cases to locate in busy locations retail, the geo-demographic profiling of store catchment areas with the highest rental density retail property. enables the optimisation of location, format, ranging and services choice based on consumer and regional characteristics. The ranges for each individual store need to be carefully tailored based on the demographics of the local population. For example, For example, there is now far greater confidence in forecasting ranges more applicable to older or younger people would expand birth rates at a local level and in turn the age profile evolution or contract based on available space and the age profile of the of individual districts and the likely mix of customers using local demographic. Advanced analytics allow the depth of stock local shopping and leisure facilities. This is critical to informing holding for each line to be optimised in order to minimise stock investment decisions that need to anticipate likely changes holding, while maximising availability. Freed up space can then be to consumer needs in the medium and longer term. It is made available to promote and sell larger items for home delivery, essential to recognise that returns on capital investment will be particularly those where expert advice from the pharmacist would overwhelmingly influenced by the pharmacy revenues achieved support the sale, e.g. wheelchairs and other mobility aids. and their growth rates.

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 9 Improved availability of data and sophisticated analytics using patient, digital engagement and purchase information will also THE OPPORTUNITY TO be increasingly used to improve the customer journey both online and in the pharmacy. The customer will also benefit from a more integrated pharmacy service concept, for example, by TRANSFORM PRIMARY better aligning the ranging and availability of OTC medicines for managing unwanted side effects with the anticipated demand HEALTHCARE for prescription medicines. We expect pharmacists to have better access to patients’ medical information to allow more informed Whilst the transformation that primary healthcare is undergoing recommendations to be made, supported by advanced diagnostic creates some economic challenges for the pharmacy sector analytics. Such personalisation should make possible better with likely reductions in prescription income in many markets, tailoring of services to the needs of the patient, while operating there is a very substantial opportunity for pharmacies to expand strictly within any data protection and other regulatory constraints. their role in the provision of primary healthcare. Drawing on the experiences of digitally-enabled business models such as those Approaches such as this, informed by advanced analytics, now seen in retail, and responding to pressure on healthcare also present significant opportunities for manufacturers of budgets, pharmacies now have a much greater opportunity to complementary OTC medicines and nutritional products to engage become a real focal point for community healthcare. The adoption with pharmacies through a patient pathway lens. Building on of the new enabling technologies described here and the effective established retail category management thinking, we expect such use of data analytics will be key to this enhanced role, allowing businesses to play an increasingly important role in the patient pharmacies to offer a wider and more customised range of health- care offered by the “pharmacy of the future.” related products and services, both in store and online.

10 HOW READY ARE YOU TO PLAY?

Do you know your customers and their households individually so that you can target them with 1 relevant information and offers?

Do you have consultation room facilities and do you offer an up-to-date range of diagnostic 2 services and treatments in the pharmacy?

3 Are you equipped to handle electronic prescriptions from local GP practices?

Do you offer electronic information services that allow your customers to find out more about 4 the conditions they are being treated for and the medications prescribed?

Are you linked with an on-line or telephone based medical consultation service with the 5 ability to fulfil on-line prescriptions in the pharmacy?

Are you using electronic patient medical record information, for example to validate 6 prescription details and risk of side-effects?

Do you allow your customers to check product availability on-line and order in advance for 7 collection in the pharmacy?

Do you provide a direct delivery service whereby products can be ordered on-line or by 8 phone and delivered direct to the customer’s home or office address?

Do you integrate the ranging and merchandising of non-prescription medicines and other 9 products to complement the mix of medicines prescribed?

For community pharmacies, does your range of non-prescription medicines and other 10 products reflect the demographics of your local catchment area?

For pharmacies in major retail destinations and transportation hubs, does your range of 11 non-prescription medicines and other products reflect the typical needs of customers passing through the location?

Do you offer other services such as ‘click and collect’ on behalf of other retailers that drive 12 traffic into the pharmacy?

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 11 Privately-held since 1983, A&M is a leading global professional HOW A&M CAN HELP services firm that delivers business performance improvement, turnaround management and advisory services to organisations A&M helps clients play a full and proactive role in the realisation seeking to transform operations, accelerate growth and achieve of the multiple opportunities these changes present through the results through decisive action. Our senior professionals are industry, technology and business model innovation skills we experienced operators, world-class consultants and industry bring. As a result, individuals will benefit from better and more leaders who leverage the firm's operational heritage to help accessible healthcare. The pressure on primary healthcare leaders turn change into a strategic business asset, manage risk systems will be relieved, thereby creating more sustainable and unlock value at every stage. economic healthcare models. Pharmacy operators will realise new Companies, investors and government entities around the world opportunities to create value by playing a much more material role turn to Alvarez & Marsal (A&M) when conventional approaches in healthcare provision tailored to the needs of local communities. are not enough to drive change and deliver results.

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GROWTH AND REVENUE ENHANCEMENT • Corporate and Business Leaders who will have the tough Unit Strategy • Customer Experience conversations about the most complex • Category Development • Sales Force Effectiveness business challenges • Revenue Management • Marketing Automation • Operational Efficiency

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CLIENT OUTCOME: Significant top & bottom line revenue improvement

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12 KEY CONTACT Lawrence Hutter

THE DIGITAL TRANSFORMATION OF HEALTHCARE: PART I, PHARMACY 13 Lawrence Hutter Chief Executive Officer [email protected]

Simon Evetts Managing Director [email protected]

Koen De Staercke Managing Director [email protected]

Tasneem Azad Managing Director [email protected]

Christopher Garner Senior Advisor [email protected]

Companies, investors and government entities around the world turn to Alvarez & Marsal (A&M) when conventional approaches are not enough to activate change and achieve results.

Privately-held since 1983, A&M is a leading global professional services firm that delivers performance improvement, turnaround management and business LEADERSHIP. advisory services to organizations seeking to transform operations, catapult growth and accelerate results PROBLEM SOLVING. through decisive action. Our senior professionals are experienced operators, world-class consultants VALUE CREATION. and industry veterans who draw upon the firm’s restructuring heritage to help leaders turn change into a strategic business asset, manage risk and unlock value at every stage. Follow us on:

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